| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
605 |
601 |
$84K |
| D1120 |
Prophylaxis - child |
1,773 |
1,763 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,234 |
2,223 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
351 |
143 |
$50K |
| D1351 |
Sealant - per tooth |
1,496 |
288 |
$40K |
| D1110 |
Prophylaxis - adult |
749 |
743 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,506 |
2,489 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
158 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,222 |
1,212 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,494 |
1,281 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,526 |
1,479 |
$18K |
| D0274 |
Bitewings - four radiographic images |
460 |
457 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
320 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
419 |
402 |
$11K |
| D0330 |
Panoramic radiographic image |
147 |
144 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
61 |
$7K |
| D0350 |
|
126 |
123 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$751.20 |
| D1330 |
|
588 |
582 |
$49.00 |
| D0603 |
|
3,183 |
3,152 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |